Question

Baby boy Brandon was born via spontaneous vaginal birth at 40 weeks of gestation in a rural hospital. Brandon’s mother reports that she initiated prenatal care during the fourth month of her pregnancy and that she had no complications during the entire pregnancy.
Upon initial assessment after birth, the nurse notices that Brandon is lethargic with mild cyanosis. The nurse immediately suctions his airway, administers oxygen via oxygen hood, and reassesses the baby. After 2 minutes, the cyanosis does not improve and the nurse now observes the following signs and symptoms:

Diminished breath sounds heard over the left lung field with asymmetrical respiratory movements

Scaphoid abdomen

Respiratory rate: 70 breaths per minute;, heart rate: 180 beats per minute; blood pressure: 65/40 mm Hg (equally in the upper and lower extremities)

Patent nares

Oxygen saturation of 89% (pulse oximetry)

Grunting, nasal flaring, and subcostal retractions

Severe cyanosis

Critical Thinking Questions
1. What is your analysis of the findings from this scenario?

2. What are the priority nursing diagnoses at this time?

3. What are the expected nursing outcomes related to this scenario?

4. Discuss the nursing interventions related to this scenario.

5. Describe the teaching/learning needs for Brandon’s family.

Answer 1

1. What is your analysis of the findings from this scenario?

Grunting is a sound produced on expiration. nasal flaring is the result of upper airway obstruction. subcostal retractions denote the decreased airway on the neonate. Scaphoid abdomen indicates that the child is suffering from a congenital diaphragmatic hernia. Tachypnea, Decreased oxygen saturation, cyanosis, respiratory symptoms indicate the child is on respiratory distress. It is a clinical condition seen in the newborn whereby the symptoms leads to respiratory failure due to dysfunction of the central nervous system.

2. What are the priority nursing diagnoses at this time?

• Impaired gas exchange related to lack of surfactant as evidenced by nasal flaring, grunting, retractions.
• altered Respiratory status related to upper airway obstruction as evidenced by tachypnea, diminished breath sounds.
• Altered nutritional status less than body requirements related to hernia as evidenced by scaphoid abdomen, poor feeding.

3. What are the expected nursing outcomes related to this scenario?

• The newborn should improve the oxygen saturation of at least 99% on room air.
• The newborn would show improved breath sounds, and absence of tachypnea, grunting.
• The newborn should show improved nutritional status.

4. Discuss the nursing interventions related to this scenario.

• Administer the oxygen.
• Monitor respiration and oxygen saturation.
• Auscultate lung sounds.
• Perform nasal/oral suctioning.
• Provide nasal feeding.
• Assist the mother in newborn bonding and parenteral nutrition.
• Monitor the blood glucose level.

5. Describe the teaching/learning needs for Brandon’s family.

• Educate the parents that the clinical condition occurred immediately after the childbirth when the lung is not developed fully.
• Educate about the oxygen and NG tube feedings necessary for the newborn.
• Educate the parents about parenteral nutrition and their needs.
• Educate the mother about the importance of bonding with the child.
• Educate about neonatal care and hygienic measures.